What is ischemic dilated cardiomyopathy?

It is a form of heart failure with left ventricular dilatation and systolic dysfunction caused by chronic myocardial ischemia and post-infarction remodeling.

What are the main risk factors?

Previous myocardial infarction, arterial hypertension, dyslipidemia, diabetes mellitus, and metabolic syndrome.

How is ischemic dilated cardiomyopathy diagnosed?

Diagnosis is based on echocardiography, ECG, cardiac MRI to assess function and fibrosis, and coronary angiography to identify critical stenoses.

What is the treatment for ischemic dilated cardiomyopathy?

It includes drugs (ACE inhibitors, beta-blockers, aldosterone antagonists, diuretics, anticoagulants), coronary revascularization, ICD, CRT, and in severe cases, heart transplantation.

What is the prognosis?

It is a chronic and progressive disease with a high risk of complications, but optimized treatment can improve survival and quality of life.

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Ischemic Dilated Cardiomyopathy

The ischemic dilated cardiomyopathy is a condition characterized by left ventricular dilatation and systolic dysfunction secondary to chronic myocardial ischemia.
It represents one of the most common causes of heart failure with reduced ejection fraction (HFrEF). The main pathophysiological mechanism is ventricular remodeling induced by repeated episodes of ischemia, myocardial necrosis and fibrosis.

The main factors involved are:

Progressive loss of cardiomyocytes: Repeated infarctions and chronic ischemia lead to apoptosis and cellular necrosis.
Myocardial fibrosis: Replacement of viable myocardial tissue with scar tissue.
Alterations in contractility: Reduced ability to generate contractile force, resulting in decreased cardiac output.
Neurohormonal activation: Increased catecholamines, angiotensin II and aldosterone, promoting the progression of myocardial damage.

Ischemic dilated cardiomyopathy is one of the leading causes of heart failure in patients with previous coronary artery disease. The main risk factor is therefore the presence of a previous myocardial infarction (which causes irreversible myocardial necrosis and ventricular remodeling) in addition to the classic traditional cardiovascular risk factors (arterial hypertension, dyslipidemias, diabetes mellitus, metabolic syndrome).

Clinical Features and Diagnosis

The main symptoms are due to left ventricular dysfunction and heart failure.

Patients may present with:

Exertional dyspnea and orthopnea.
Peripheral edema and systemic venous congestion.
Exercise intolerance and easy fatigability.
Palpitations and ventricular arrhythmias.

Diagnostic tools include:

ECG: Repolarization abnormalities, Q waves from previous infarction, arrhythmias.
Echocardiogram: Left ventricular dilatation, reduced ejection fraction, segmental wall motion abnormalities.
Cardiac Magnetic Resonance Imaging: Evaluates myocardial fibrosis and residual viability.
Coronary angiography: Essential for identifying critical coronary stenoses.

Treatment of Ischemic Dilated Cardiomyopathy

The aim of treatment is to improve ventricular function, reduce symptoms and prevent disease progression.

Lifestyle modifications: A low-sodium diet, controlled physical activity, smoking cessation and blood pressure management improve prognosis.

Pharmacological therapy:

ACE inhibitors and sartans: Reduce afterload and ventricular remodeling.
Beta-blockers: Improve ventricular function and reduce mortality.
Aldosterone antagonists: Inhibit myocardial fibrosis.
Diuretics: Control pulmonary and peripheral congestion.
Anticoagulants: Essential in patients with atrial fibrillation or intracardiac thrombi.

Myocardial revascularization: In patients with significant ischemia, coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) can improve ventricular function.

Advanced therapy: In patients with advanced heart failure, the following may be required:

Implantable cardioverter-defibrillator (ICD) for the prevention of sudden death.
Cardiac resynchronization therapy (CRT) in patients with ventricular dyssynchrony.
Heart transplantation in the most severe cases.

Prognosis and Complications

Ischemic dilated cardiomyopathy is a progressive condition, with a high risk of refractory heart failure, ventricular arrhythmias and sudden death. However, optimized treatment can significantly improve quality of life and survival.

References

Ponikowski P, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37(27):2129-2200.
Yancy CW, et al. ACC/AHA Guidelines for the management of heart failure. Circulation. 2017;136(6):e137-e161.
Shah AM, et al. Pathophysiology of heart failure with reduced ejection fraction. Circulation. 2017;135(6):518-531.
McDonagh TA, et al. Heart failure management in coronary artery disease. J Am Coll Cardiol. 2021;77(19):2392-2405.
Groenewegen A, et al. Epidemiology of heart failure. J Am Coll Cardiol. 2020;75(12):1475-1487.
Cleland JGF, et al. Medical therapy in ischemic cardiomyopathy. BMJ. 2018;360:k134.
Felker GM, et al. Management of dilated cardiomyopathy. NEJM. 2018;379(25):2524-2536.
Velagaleti RS, et al. Risk factors for the development of heart failure. J Am Coll Cardiol. 2019;73(22):2701-2710.
Jessup M, et al. Left ventricular assist devices in advanced heart failure. Circulation. 2017;135(24):2591-2602.
Goldberger JJ, et al. Implantable cardioverter-defibrillators in heart failure. JAMA. 2020;323(11):1045-1055.